Provider Demographics
NPI:1366847592
Name:WAGNER, GRACE (PROFESSIONAL COUNSEL)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:WAGNER
Suffix:
Gender:F
Credentials:PROFESSIONAL COUNSEL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4314 OLD WILLIAM PENN HIGHWAY
Mailing Address - Street 2:SUITE 204
Mailing Address - City:MONROEVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15146
Mailing Address - Country:US
Mailing Address - Phone:412-352-6634
Mailing Address - Fax:412-829-7240
Practice Address - Street 1:4314 OLD WILLIAM PENN HIGHWAY
Practice Address - Street 2:SUITE 204
Practice Address - City:MONROEVILLE
Practice Address - State:PA
Practice Address - Zip Code:15146
Practice Address - Country:US
Practice Address - Phone:412-352-6634
Practice Address - Fax:412-829-7240
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-30
Last Update Date:2017-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA007839101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor